Abnormal Uterine Bleeding · Dysfunctional uterine bleeding (DUB) Classification System PALM-COEIN...
Transcript of Abnormal Uterine Bleeding · Dysfunctional uterine bleeding (DUB) Classification System PALM-COEIN...
Abnormal Uterine
BleedingDr. Brett Vair, MD FRCSC, Obstetrics & Gynecology
45th Dalhousie Annual Spring Refresher Course
March 8, 2019
Disclosure
• In the past, I have been a presenter with Bayer (2016)
• Mitigating potential bias:
• The content of this presentation is based on best practice
and evidence based medicine
Outline
• Terminology and classification
• Clinical evaluation
• Laboratory investigations
• Imaging studies
• When should endometrial biopsy be considered?
• Overview of medical treatment
• Nonhormonal vs. hormonal options
• When is referral to Gynecology indicated?
A common problem…
• Menstrual disorders are a common indication for medical
visits
• Heavy menstrual bleeding affects up to 30% of women in
their reproductive lifetime
• Significant impact on:
• Quality of life
• Time off work
• Health care system
Definitions
AUB = Any variation from the normal menstrual cycle
• Includes changes in:
• Regularity and frequency of menses
• Duration of flow
• Amount of blood loss
Definitions
• Heavy menstrual bleeding
• The most common complaint of AUB
• “Excessive menstrual blood loss which interferes with the
woman’s physical, social, and emotional, and/or material
quality of life”
Terminology
Menorrhagia
Metrorrhagia
Dysfunctional uterine bleeding (DUB)
Classification System
PALM-COEIN(FIGO, 2011)
ACOG Practice Bulletin No. 128: Diagnosis of Abnormal Uterine Bleeding in Reproductive-
Aged Women. July, 2012
Evaluation of AUB Laboratory Investigations
• Recommended investigations:
• CBC (II-2A)
• Urine or serum βhCG ((III-C)
• Cervical cancer screening
• Testing for Chlamydia trachomatis in patients at high risk
• TSH
• *Only if there are symptoms or findings suggestive of thyroid
disease (II-2D)
• Testing for coagulation disorders in women with risk factors(II-2B)
Of all women presenting with heavy menstrual
bleeding, which percentage will ultimately be
found to have an underlying bleeding disorder?
A. 1%
B. 3-5%
C. 10-20%
D. 30%
When should testing for bleeding
disorders be ordered?
• History of heavy, regular, cyclic periods since menarche
• Up to 50% of adolescents presenting with heavy bleeding at
menarche will have a coagulopathy
• Personal or family history of abnormal bleeding
• Recommended testing:
• INR, PTT
• Special testing for Von Willebrand’s disease (factor VIII
level, vWF antigen, and vWF functional assay)
• There is no evidence for routine measurement of:
• Ferritin
• TSH if there is no reason to suspect thyroid disease
• FSH, LH
• Estradiol
• Progesterone
Evaluation of AUB Laboratory Investigations
• Imaging studies may be indicated when:
• History or physical exam suggests structural causes
• There is a risk of malignancy
• Conservative management has failed
Evaluation of AUB Imaging Studies
• Transvaginal ultrasound should be the first line imaging
modality for investigation of AUB (I-A)
• Assists with diagnosis of:
• Endometrial polyps
• Leiomyomas
• Adenomyosis
• Uterine anomalies
• Endometrial thickening associated with hyperplasia and
malignancy
Evaluation of AUB Imaging Studies
A quick word about uterine
fibroids…• Found in 70% of women by age 50
• 30% of women experience AUB
• The majority are asymptomatic and do not require
intervention
• Submucous fibroids that protrude into the uterine cavity
are most frequently related to AUB
• Women with intramural fibroids may also experience
AUB
… And a quick word about
endometrial polyps…
• Localized hyperplastic overgrowths of endometrial tissue
that form a projection from the surface of the
endometrium
• Majority are benign (95%)
• May be asymptomatic
• Intermenstrual bleeding is the most frequent symptom
A 42 year-old premenopausal woman has a
transvaginal ultrasound reporting a thick
endometrium measuring 15 mm.
Should this finding alone prompt concern about
endometrial hyperplasia or malignancy?
A. Yes
B. No
Ultrasound endometrial
assessment
• The normal endometrium in a premenopausal woman varies in thickness according to the menstrual cycle
• 4 mm in the follicular phase
• Up to 16 mm in the luteal phase
• There is no standard threshold for abnormal endometrial thickness in premenopausal women
• Further evaluation should be based on the specific clinical situation
When should endometrial
biopsy be considered?
• Age >40
• Risk factors for endometrial cancer
• Failure of medical treatment
• Significant intermenstrual bleeding
• Anovulatory menstrual cycles
(Level of evidence: II-2A)
Endometrial cancer risk
factors• Age
• Average age 61 years
• 5%-30% of cases occur in premenopausal women
• Obesity (BMI >30 kg/m2)
• Nulliparity
• PCOS
• Diabetes
• HNPCC
• Lifetime risk for endometrial cancer 40-60%
Differentiating ovulatory from
anovulatory menstrual cycles
• Anovulatory bleeding is more likely to be associated with
endometrial hyperplasia and malignancy
Ovulatory bleeding Anovulatory bleeding
• Regular menstrual cycles
• Associated with
premenstrual symptoms
and dysmenorrhea
• Irregular
• Heavy
• Prolonged
• Common near menarche
and the perimenopause
Managing abnormal bleeding
in the perimenopausal patient
“…all women older than 45 years who
present with suspected anovulatory uterine
bleeding should be evaluated with
endometrial biopsy…”
- American College of Obstetricians and Gynecologists Practice
Bulletin No. 136, 2013
Medical Treatment
• The first line therapeutic option
• Should be initiated once malignancy and significant
pelvic pathology have been ruled out
• Women found to be anemic from AUB should be started
on iron supplementation immediately
Medical TreatmentEffective medical treatment options for abnormal uterine bleeding
Non-hormonal options Non-steroidal anti-inflammatory drugs (I-A)
Antifibrinolytics (I-A)
Hormonal options Combined hormonal contraceptives (I-A)
LNG-IUS (I-A)
Oral progestins
Depot-medroxyprogesterone acetate (I-A)
Danazol (I-C)
GnRH agonists (I-C)
NSAIDs• Cochrane Review 2007:
• Reduction of menstrual blood loss by 33%-55% vs. placebo
• No significant difference in adverse effects
• Improvement in dysmenorrhea in up to 70% of patients
• Therapy ideally begins the day before menses and continues for 3-5
days or until bleeding ceases
• Clinical trials comparing NSAIDs to other medical agents have
found them to be less effective in reducing menstrual blood loss
Medical Treatment: Non-hormonal options
Antifibrinolytics (tranexamic acid)
• Placebo-controlled trials: reduction in menstrual blood
loss 40%-59% from baseline
• Most commonly studied regimen: 1 g po q6h during
menstruation
• Single daily dose of 4 g also found to be effective
• Does not treat dysmenorrhea
• Controversy regarding possible elevated risk of venous
thromboembolism
Medical Treatment: Non-hormonal options
Combined hormonal contraceptives
• Advantages:
• Cycle control
• Reduction of menstrual losses
• 40%-50%
• Improvement of dysmenorrhea
• Contraception
• Continuous use may offer superior effect
Medical Treatment: Hormonal options
The levonorgestrel-releasing intrauterine system (LNG-IUS)
• Approved by Health Canada for treatment of heavy menstrual bleeding
• 70%-97% reduction in blood loss
• Amenorrhea in up to 80% at one year
• Other advantages:• Contraception
• Treatment of dysmenorrhea, pelvic pain due to endometriosis
• Cochrane Review 2006:
• LNG-IUS provides equivalent improvement in quality of life vs. surgical treatment options
Medical Treatment: Hormonal options
A 14 year-old female presents to your office with
heavy, irregular menstrual periods. She has never
been sexually active. Is the levonorgestrel-releasing
intrauterine system a treatment option that may be
discussed with her?
A. Yes
B. No
Oral progestins• A recognized treatment for anovulatory bleeding
• Cyclic progestins taken for 12-14 days each month
• 50% of women with irregular cycles will achieve menstrual
regularity
• Offer endometrial protection from effects of unopposed
estrogen
• Not an effective treatment for regular heavy menstrual
bleeding (I-E)
Medical Treatment: Hormonal options
When is referral to
Gynecology indicated?• Acute presentation of AUB
• Severe iron-deficiency anemia
• Failure of conservative treatment
• Concern about possible malignancy
• Focal endometrial lesion
• Structural uterine abnormalities
• Endometrial biopsy indicated
• Desire for surgical treatment
Summary• AUB is a common condition which has a significant
impact both at the individual level, and at the level of the
health care system
• Recommended investigations: CBC, BhCG, cervical
screening, cervical swabs
• TSH and coagulopathy screening if clinically indicated
• TVUS is the first-line imaging modality for AUB
Summary• Endometrial biopsy should be considered in women >40
years or in those with bleeding not responsive to medical therapy
• Also in younger women with risk factors for endometrial cancer
• Medical treatment is the first-line therapeutic option
• Both non-hormonal and hormonal options may be considered
Resources
• ACOG Practice Bulletin No. 128: Diagnosis of Abnormal
Uterine Bleeding in Reproductive-Aged Women. Obstetrics &
Gynecology, July 2012; 120 (1).
• ACOG Practice Bulletin No. 136: Management of Abnormal
Uterine Bleeding Associated with Ovulatory Dysfunction.
Obstetrics & Gynecology, July 2013; 122 (1).
• SOGC Clinical Practice Guideline No. 292: Abnormal Uterine
Bleeding in Pre-Menopausal Women. J Obstet Gynaecol Can,
May 2013; 35: S1-S28.
Questions?